Corydon Dental Centre - Medical and Dental information

First Name *

Last Name *

PATIENT MEDICAL FORM

1 - DATE OF BIRTH *

GENDER *

Please answer this question.

2 - ADDRESS *

3 - POSTAL CODE *

4 - TELEPHONE/ MOBILE: *

5 - EMAIL ADDRESS: *

DO YOU HAVE INSURANCE? IF YES, WHO IS YOUR INSURANCE PROVIDER

HAVE YOU HAD XRAYS IN THE PAST 2 YEARS? IF YES, AT WHICH OFFICE?

6 - Are you being treated for any medical conditions at the present time or have been treated within the last year *

NoYesNo

7 - when was you last medical check up?

8 - Have there been any changes in your general health in the last year?

NoYesNo

9 - Are you taking any medications, non prescription drugs or herbal supplements of any kind?

NoYesNo

10 - Do you have any allergies? Medications, latex or rubber products or other?

NoYesNo

11 - Have you ever had an uncommon or adverse reaction to any medications or injections?

NoYesNo

12 - Do you have or have you ever had asthma?

NoYesNo

13 - Do you have or have had any heart or blood pressure problems?

NoYesNo

14 - Do you have or have ever had a replacement or repair of a heart valve, an infection of the heart, heart condition from birth or a heart transplant? *

NoYesNo

15 - Have you ever had hepatitis, jaundice or liver disease? *

NoYesNo

16 - Do you have a prosthetic or an artificial joint?

NoYesNo

17 - Do you have a bleeding problem or a bleeding disorder?

NoYesNo

18 - Have you ever been hospitalized for any illness or operations?

NoYesNo

19 - do you have any conditions or therapies that could affect your immune system, e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?

NoYesNo

20 - Do you have , or have ever had any of the following? AIDS, Alzheimers, Angina, Anemia, Arthritis, Blood Transfusion, Cancer, Chest Pain, Cold Sores, Diabetes type 1, Diabetes type 2, Digestive Disorders/Acid Reflux, Drug/Alcohol dependency, Emphysema, Epilepsy or Seizures, Fibromyalgia, Head/Neck injury, Heart Attack, Heart mumur, High/ low blood pressure, HIV, Hodgkins disease *

NoYesNo

21 - Do you have or have you ever had any of the following? Hypo/Hperglycemia, Kidney disease, Lung disease, Lupus, Migraine, Mitral Valve Prolapse, Osteoporosis Medications, Parkinson disease, Radiation/Chemotherapy, Rheumatic fever, Sexually Transmitted Infection, Shortness of Breath, Sleep Apnea, Steroid Therapy, Stomach Ulcers, Stroke, Thrush, Thyroid Disorder, TMJ Disorder, Tuberculosis *

NoYesNo

22 - Are there any conditions or disease not listed above that you have or have had?

NoYesNo

23 - Are there any diseases or medical conditions that run in your family? (eg. diabetes, cancer or heart disease)

NoYesNo

24 - Do you smoke or chew tobacco products?

NoYesNo

25 - Are you nervous during dental treatment?

NoYesNo

26 - Are you pregnant?

NoYesNo

DENTAL HISTORY

When was your last dental visit?

When did you last have dental x rays taken?

How often do you brush your teeth?

How often do you floss?

Have you been seeing a dentist regularily?

NoYesNo

Do any of your teeth ache?

NoYesNo

Have you been advised to take antibiotics before dental appointments?

NoYesNo

Do your gums bleed when you brush?

NoYesNo

Do you have any pain when you chew?

NoYesNo

Do you feel you have bad breath

NoYesNo

Have you ever been in a vehicle accident or experienced any trauma to your jaw?

NoYesNo

Have you ever had any implant surgery?

NoYesNo

If you answered yes to the last question, who performed the surgery and when was it done?

Are you being followed by a dental specialist?

Do you have any problems with your jaw joint (pain, sounds, limited opening, locking, popping)?

NoYesNo

Is there anything about the appearance of your teeth you would like to change?

Please list anything not mentioned above regarding your past dental history?

Medical and Dental information - Corydon Dental Centre

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The information has been received.

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PATIENT MEDICAL FORM

DENTAL HISTORY

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